CDE Appendix 1 Literature Review - Central East Local Health ...

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The Culture, Diversity and Equity Project: Literature Review This intervention model cascades down from top to bottom from the more to less determining causes of health and health in/equity, emphasizing the role of structural system factors and conditions in particular. The model is both theoretically informed and comprehensive in scope, considering the full range of factors influencing health inequalities, whilst illuminating potential sites and entry points for intervention. Below is a listing of the corresponding sites for intervention and types of initiatives envisioned on the basis of this intervention framework: Level 1: Structural – social, economic, cultural and historical factors fundamentally determine health “The most fundamental approach to reducing inequalities in health is to tackle their root cause; that is, address the social, cultural, economic and historical inequalities themselves. This requires policies directly concerned with education, occupation, income and the Economy” (Ministry of Health 2002, p.20). The New Zealand Framework for Reducing Inequalities in Health lists the following potential roles for the health sector in reducing inequalities that are ‘upstream’ from the health system: • Health sector workers can contribute by drawing attention to the social and economic determinants of health and advocating for policies in other sectors that will improve health and reduce health inequalities. • We [the health sector] should also work collaboratively with other sectors to develop and implement a more comprehensive range of strategies to tackle specific health problems than we could apply relying on health services alone. [The example of health impact assessment across Ministries is given as a potential strategy; see Accountability section for more on uses of health equity impact assessment tools in this and other respects] • The health sector also has a direct role at the strategic level; namely, it should ensure that its own policies are directed towards a more equitable distribution of health resources in relation to inequalities in health status. Specific examples of the types of action that may be taken at this level include: • Systematic implementation of the provisions of the Treaty of Waitangi in policy, planning and service delivery • Health funding arrangements that distribute resources according to need • Exploration of health impact assessment tools • Monitoring of health inequalities, social determinants and the relationship between the two • Development of Maori and Pacific providers and workforce (p.20-21) Level 2: Intermediary pathways – the impact of social, economic, cultural and historical factors on health status is mediated by various factors “The effect of socioeconomic position on health is mediated by a number of material, psychosocial and behavioural factors, which may provide effective intervention points” (p.21). The following examples of potential actions at this level are provided: • Housing initiatives • Community development programmes • Settings-based programmes, such as healthy cities and health-promoting schools • Workplace interventions (for example, occupational safety and health) • Local authority policies (for example, in relation to cycleways, lighting, playgrounds • And transport) • Health education and the development of personal skills • Health protection. 26
The Culture, Diversity and Equity Project: Literature Review Level 3: Health and disability services – what services can specifically do This level of action focuses in on “the significant part to play” of disability and health care services in reducing inequalities, namely by: • Ensur[ing] equity of access to care by distributing resources in relation to need, as defined in collaboration with local communities; and • Remov[ing] barriers, however defined, that inhibit the effective use of services for all ethnic and social groups (p.21; citing Benzeval et al., 1995). Examples provided of actions and interventions at this level include: • Improved access to appropriate, high-quality health care and disability services • Collection of accurate ethnicity data • Implementation of the elective services booking system based on need • Monitoring of service delivery to ensure equitable intervention rates according to ethnicity, gender, socioeconomic status and region • Primary care initiatives that reduce access barriers for maori, pacific peoples and other disadvantaged groups • Ethnic-specific service delivery • Community participation in the health sector at a governance level and in resource allocation decision-making • Equitable resource allocation by district health boards as funders and by providers, including hospitals • Collaborative partnerships within the health sector and intersectorally (pp.21-22). Level 4: Impact – minimising the impact of disability and illness on socioeconomic position “[T]hose who are chronically ill, or have a disability or mental illness, face higher risks of downward mobility through lower educational achievement, greater problems in finding and keeping a job and fewer opportunities for upward mobility within a job” (New Zealand Ministry of Health, 2002:22). Examples provided of remedial actions at this level include: • Income support (for example, sickness benefits) • Disability allowance • Accident compensation • Antidiscrimination legislation and education; and • Support services for people with disabilities, chronic illness and mental health illness WHO Closing the Gap Framework The Commission on Social Determinants of Health was set up by former World Health Organization Director- General JW Lee and given the task “to collect, collate, and synthesize global evidence on the social determinants of health and their impact on health inequity, and to make recommendations for action to address that inequity” (WHO 2008). The findings from this inquiry are reported in the WHO’s (2008) report, Closing the Gap in a Generation: Health equity through action on the social determinants of health. As suggested by the title, the WHO Commission takes a holistic determinant of health approach in its effort to identify and remedy inequities in health status which go far beyond the health care system. The ‘principles of action’ and corresponding interventions recommended in this report are “underpinned by an aetiological conceptual framework” that is modeled below (Figure 2.9). 27
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